60 Nutrition in Head and Neck Cancer
Nutrition is a key modality in the treatment and effective management of patients diagnosed with head and neck cancer. Patients can be malnourished at presentation, and many patients undergoing treatment for head and neck cancer will need nutritional support. Early identification of high risk patients and intervention with nutrition support should be included as part of the planning for every patient when treatment options are being considered. This should include quality-of-life (QoL) issues to address psychosocial, rehabilitation and survivorship needs of patients and carers. The dietitian is a core member of the multiprofessional team and the team specialist for leading multidisciplinary discussion and decision making for all nutrition related issues.
60.1 Nutritional Screening and Monitoring
Nutritional screening of patients in an outpatient setting and on admission to hospital, identifies those at risk, allowing early nutritional intervention to correct deficiencies and optimise nutritional status prior to treatment.
Basic nutritional parameters to consider are:
• Nutritional intake (change in texture or volume).
• Impaired swallow.
• Weight change and body mass index (BMI).
Nutritional screening should be undertaken using a validated screening tool and continued regularly throughout treatment to monitor impact of treatment on nutritional status.
Validated screening tools available:
• Subjective global assessment (SGA).
• Patient-generated SGA.
• Malnutrition screening tool (MST).
• Malnutrition universal screening tool (MUST).
Screening should be undertaken weekly for inpatients to monitor the effects of nutritional intervention. Outpatients should have their weight recorded at each visit and unintentional weight loss of 2 kg within a 2-week period should be referred onto the dietitian.
60.2 Impact of Malnutrition
Patients with head and neck cancer are at risk of malnutrition due to the site of the disease, the disease process itself, the treatment and lifestyle factors such as excessive alcohol intake. Unintentional weight loss of 10% or greater in the preceding 6 months is a sign of malnutrition regardless of presenting BMI.
Morbidities associated with malnutrition include:
• Delayed wound healing.
• Increased risk of infection and post-operative infection.
• Reduced response to non-surgical treatments.
• Muscle wasting.
Early nutritional intervention can minimise nutritional losses and improve clinical outcomes.
60.3 Nutritional Assessment
A full nutritional assessment should be undertaken once patients are identified as being malnourished or at risk of malnutrition. This should consider a variety of parameters including ability to chew and swallow, changes in texture, changes in appetite, anthropometry (including percentage weight change), nutritional intake, biochemistry and social information. This should be reassessed throughout the patient’s treatment.
60.4 Cancer Cachexia
Cachexia syndrome is a multifactorial problem that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment. Cytokine-induced metabolic alterations can prevent cachectic patients from regaining body cell mass during nutritional support and are not relieved by conventional nutritional intervention. As a minimal goal, body weight should be maintained and further loss prevented. The management approach should include assessment and ongoing monitoring with intensive nutritional support, anti-inflammatory treatment, symptom control as well as oncological treatment options to reduce the catabolic effect of the cancer.
60.5 Estimating Nutritional Requirements
Cancer itself does not have a consistent effect on resting energy expenditure (REE) but energy requirements will be affected by solid tumours, surgery in the last 7 days, oncological treatments, metabolic state, activity levels, nutritional status, phase of illness, age and sex.
Basic calculations for energy and protein requirements are highlighted below but may be less accurate for severely malnourished patients, multiple comorbidities or morbidly obese patients. Patients at risk of refeeding syndrome will require a different calculation for energy requirements.
25 to 35 kcal/kg/day dependant on activity level. It can increase further, if major complications occur.
0.8 to 2.0 g/kg/day for depleted or treatment complications.
30 to 35 mL/kg/day, increases in infection and excessive fluid losses.
Vitamins and minerals
As per recommended daily amounts unless considered deficient.
60.6 Refeeding Syndrome
This potentially lethal condition can be defined as severe fluid and electrolyte shifts associated with metabolic abnormalities in patients who have had little or no food for more than 5 days, on the reintroduction of nutrition via the enteral (including nutritional supplements taken via the oral route) or parenteral feeding route.
Criteria for determining people at moderate or high risk of developing refeeding syndrome:
1. Patient has one or more of the following:
• BMI less than 16 kg/m2.
• Unintentional weight loss greater than 15% within last 3 to 6 months.
• Little of no nutritional intake for more than 10 days.
• Low levels of potassium, phosphate or magnesium prior to feeding.
2. Or patient has two or more of the following:
• BMI less than 18.5 kg/m2.
• Unintentional weight loss greater than 10% within last 3 to 6 months.
• Little or no nutritional intake for more than 5 days.
• A history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics.
60.7 Refeeding Syndrome Flow Chart
All patients requiring nutrition support whether via enteral (including oral) or parenteral route should be referred to the dietitian.
60.8 Nutrition Support
The aims of nutrition support are to:
• Maintain or improve food intake and mitigate metabolic derangements.
• Maintain skeletal muscle mass and physical performance.
• Reduce the risk of reductions or interruptions of scheduled anticancer treatments.
• Improve QoL.
Nutritional support should be considered in the following scenarios:
• BMI < 18.5kg/m2.
• Unintentional weight loss > 10% over 3 to 6 months
• A BMI < 20 kg/m2 and unintentional weight loss over 3 to 6 months.
• Minimal intake for more than 5 days.
• Increased nutritional requirements due to catabolism.
60.8.1 Types of Nutrition Support
Nutritional counselling should be tailored to meet the needs of the patient and be realistic for the patient to achieve. There are three main methods of nutrition support: oral, enteral and parenteral. Parenteral nutrition support is rarely used in the head and neck cancer setting. It should, however, be considered if required.
60.8.2 Oral Nutrition Support
Nutritional interventions include review of therapeutic diets, for example lipid lowering, and introduction of food fortification as first-line advice to prevent nutritional decline. Patients may require more intensive nutritional support methods from the beginning of treatment over and above traditional food fortification methods with the early use of oral nutritional supplements, for example nutritionally complete liquid supplements. There are a variety of oral nutritional support products available. The choice will depend on patient preference, current macro and micro nutrient intake and local availability of nutritional products.
60.8.3 Enteral Nutrition Support
Tube feeding is indicated when patients are unable to take adequate nutrition orally (oral intake < 50% for more than 7 days) or early post-operative oral nutrition (within 24 hours) cannot be initiated. The choice of feeding route will depend on local arrangements and the optimal timing for decision making is at diagnosis. NICE 2016 guidance recommends clinical and non-clinical factors for risk stratification when selecting which people would benefit from short- or long-term enteral nutrition.
Short-term feeding routes (less than 30 days):
• Nasogastric, orogastric, nasojejunal, tracheo-oesophageal fistulae tubes.
Long-term feeding routes (more than 30 days):